Form 9350-1 Form R

Form Approved OMB Number: 2070-0093
Approval Expires: 01/31/2008

(IMPORTANT: Type or print; read instructions before completing form)

FORM R

EPA
United States
Environmental Protection Agency

Page 1 of 5

TRI Facility ID Number

Section 313 of the Emergency Planning and Community
Right-to-Know Act of 1986, also Known as Title III of the
Superfund Amendments and Reauthorization Act

Toxic Chemical, Category or Generic Name

WHERE TO SEND COMPLETED FORMS: 1. TRI Data Processing Center
2. APPROPRIATE STATE OFFICE
P. O. Box 1513
(See instructions in Appendix E)
Lanham, MD 20703-1513
ATTN: TOXIC CHEMICAL RELEASE INVENTORY

Enter “X” here if
this is a revision
For EPA use only

IMPORTANT: See instructions to determine when “Not Applicable (NA)” boxes should be checked.

PART 1. FACILITY IDENTIFICATION INFORMATION
SECTION 1. REPORTING YEAR
SECTION 2. TRADE SECRET INFORMATION
Are you claiming the toxic chemical identified on page 2 trade secret?
2.1

No (Do not answer 2.2; 2.2 Is this copy
Sanitized
Go to Section 3)
(Answer only if “YES” in 2.1)

Yes (Answer question 2.2;
Attach substantiation forms)

SECTION 3. CERTIFICATION

Unsanitized

(Important: Read and sign after completing all form sections.)

I hereby certify that I have reviewed the attached documents and that, to the best of my knowledge and belief, the submitted information is true and complete and that
the amounts and values in this report are accurate based on reasonable estimates using data available to the preparers of this report.
Name and official title of owner/operator or senior management official:

Signature:

Date Signed:

SECTION 4. FACILITY IDENTIFICATION
4.1

TRI Facility ID Number
Facility or Establishment Name or Mailing Address (If different from street address)

Facility or Establishment Name
Street

Mailing Address

City/County/State/Zip Code

City/State/Zip Code

4.2 This report contains information for:
(Important: Check a or b; check c or d if applicable) a.
4.3

An entire
facility

b.

Country (Non-US)
Part of a
facility

c.

A Federal
facility

GOCO

d.

Telephone Number (include area code)

Technical Contact Name
Email Address

4.4 Public Contact Name

4.5

NAICS Code (s)
(6 digits)

Telephone Number (include area code)
Primary

a.

4.7 Dun & Bradstreet
Number (s) (9 digits)

b.

c.

a.
b.

SECTION 5. PARENT COMPANY INFORMATION
5.1

Name of Parent Company

NA

5.2 Parent Company’s Dun & Bradstreet Number

NA

EPA Form 9350 -1 (Rev. 08/2006) - Previous editions are obsolete.

d.

e.

f.

Form Approved OMB Number: 2070-0093
(IMPORTANT: Type or print; read instructions before completing form)

Approval Expires: 01/31/2008

Page 2 of 5

TRI Facility ID Number

FORM R
Toxic Chemical, Category or Generic Name

PART II. TOXIC CHEMICAL RELEASE INVENTORY REPORTING FORM
SECTION 1. TOXIC CHEMICAL IDENTITY

(Important: DO NOT complete this section if you completed Section 2 below.)

1.1 CAS Number (Important: Enter only one number exactly as it appears on the Section 313 list. Enter category code if reporting a chemical category.)
1.2 Toxic Chemical or Chemical Category Name (Important: Enter only one name exactly as it appears on the Section 313 list.)
Generic Chemical Name (Important: Complete only if Part 1, Section 2.1 is checked “yes”. Generic Name must be structurally descriptive.)

1.3

1.4 Distribution of Each Member of the Dioxin and Dioxin-like Compounds Category.

(If there are any numbers in boxes 1-17, then every field must be filled in with either 0 or some number between 0.01 and 100. Distribution should
be reported in percentages and the total should equal 100%. If you do not have speciation data available, indicate NA.)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

16

17

NA

SECTION 2. MIXTURE COMPONENT IDENTITY

(Important: DO NOT complete this section if you completed Section 1 above.)

Generic Chemical Name Provided by Supplier (Important: Maximum of 70 characters, including numbers, letters, spaces and punctuation.)

2.1

SECTION 3. ACTIVITIES AND USES OF THE TOXIC CHEMICAL AT THE FACILITY
(Important: Check all that apply.)

Manufacture the toxic chemical:

3.1
a.

c.
d.
e.
f.

b.
Produce
Import
If produce or import
For on-site use/processing
For sale/distribution
As a byproduct
As an impurity

3.2

a.
b.
c.
d.
e.

Process the toxic chemical:
As a reactant
As a formulation component
As an article component
Repackaging
As an impurity

3.3

Otherwise use the toxic chemical:

a.
b.
c.

As a chemical processing aid
As a manufacturing aid
Ancillary or other use

SECTION 4. MAXIMUM AMOUNT OF THE TOXIC CHEMICAL ONSITE AT ANY TIME DURING THE CALENDAR YEAR
(Enter two digit code from instruction package.)

4.1

SECTION 5.

QUANTITY OF THE TOXIC CHEMICAL ENTERING EACH ENVIRONMENTAL MEDIUM ONSITE
A. Total Release (pounds/year*)
(Enter a range code** or estimate)

5.1

Fugitive or non-point
air emissions

5.2

Stack or point
NA
air emissions
Discharges to receiving streams or
water bodies (enter one name per box)

5.3

B. Basis of Estimate
(enter code)

C. % From Stormwater

NA

Stream or Water Body Name
5.3.1
5.3.2
5.3.3
If additional pages of Part II, Section 5.3 are attached, indicate the total number of pages in this box
and indicate the Part II, Section 5.3 page number in this box.
(example: 1,2,3, etc.)
EPA Form 9350 -1 (Rev. 08/2006) - Previous editions are
obsolete.

*For Dioxin or Dioxin-like compounds, report in grams/year.
** Range Codes: A= 1-10 pounds; B= 11-499 pounds; C= 500-999 pounds.

Form Approved OMB Number: 2070-0093
Approval Expires: 01/31/2008

(IMPORTANT: Type or print; read instructions before completing form)

Page 3 of 5

TRI Facility ID Number

FORM R
PART II. CHEMICAL - SPECIFIC INFORMATION (CONTINUED)

Toxic Chemical, Category or Generic Name

SECTION 5. QUANTITY OF THE TOXIC CHEMICAL ENTERING EACH ENVIRONMENTAL MEDIUM ONSITE (continued)
NA
5.4.1

Underground Injection onsite
to Class I Wells

5.4.2

Underground Injection onsite
to Class II-V Wells

5.5

Disposal to land onsite

B. Basis of Estimate
(enter code)

A. Total Release (pounds/year*) (enter range
code ** or estimate )

5.5.1A RCRA Subtitle C landfills
5.5.1B Other landfills
Land treatment/application
farming
RCRA Subtitle C
5.5.3A surface impoundments

5.5.2

5.5.3B Other surface impoundments
5.5.4

Other disposal

SECTION 6. TRANSFERS OF THE TOXIC CHEMICAL IN WASTES TO OFF-SITE LOCATIONS
6.1 DISCHARGES TO PUBLICLY OWNED TREATMENT WORKS (POTWs)
6.1.A Total Quantity Transferred to POTWs and Basis of Estimate
6.1.A.2
6.1.A.1 Total Transfers (pounds/year*)
(enter range code ** or estimate)

Basis of Estimate
(enter code)

POTW Name

6.1.B
POTW Address
City

State

County

Zip

State

County

Zip

POTW Name

6.1.B
POTW Address

City

If additional pages of Part II, Section 6.1 are attached, indicate the total number of pages
in this box
and indicate the Part II, Section 6.1 page number in this box

(example: 1,2,3, etc.)

SECTION 6.2 TRANSFERS TO OTHER OFF-SITE LOCATIONS
6.2.

Off-Site EPA Identification Number (RCRA ID No.)

Off-Site Location Name
Off-Site Address
City

State

Is location under control of reporting facility or parent company?
EPA Form 9350 -1 (Rev. 08/2006) - Previous editions are
obsolete.

Country
(Non-US)

Zip

County
Yes

No

* For Dioxin or Dioxin-like compounds, report in grams/year
** Range Codes: A=1-10 pounds: B=1-499 pounds; C=500 - 999 pounds.

Form Approved OMB Number: 2070-0093
Approval Expires: 01/31/2008

(IMPORTANT: Type or print; read instructions before completing form)

Page 4 of 5

TRI Facility ID Number

FORM R
PART II. CHEMICAL-SPECIFIC INFORMATION (CONTINUED)

Toxic Chemical, Category or Generic Name

SECTION 6.2 TRANSFERS TO OTHER OFF-SITE LOCATIONS (CONTINUED)
A. Total Transfers (pounds/year*)
(enter range code**or estimate)

B. Basis of Estimate
(enter code)

C. Type of Waste Treatment/Disposal/
Recycling/Energy Recovery (enter code)

1.

1.

1. M

2.

2.

2. M

3.

3.

3. M

4.

4.

4. M

Off-Site EPA Identification Number (RCRA ID No.)

6.2

Off-Site Location Name
Off-Site Address
State

City

County

Is location under control of reporting facility or parent company?
A. Total Transfers (pounds/year*)
(enter range code**or estimate)

Zip

Country
(Non-US)

Yes

No

B. Basis of Estimate
(enter code)

C. Type of Waste Treatment/Disposal/
Recycling/Energy Recovery (enter code)

1.

1.

1. M

2.

2.

2. M

3.

3.

3. M

4.

4.

4. M

SECTION 7A. ON-SITE WASTE TREATMENT METHODS AND EFFICIENCY
Not Applicable (NA) a. General
Waste Stream
[enter code]

7A.1a

7A.2a

7A.3a

7A.4a

7A.5a

Check here if no on-site waste treatment is applied to any
waste stream containing the toxic chemical or chemical category.
b. Waste Treatment Method(s) Sequence
[enter 3- or 4- character code(s)]

7A.1b

1

2

3

4

5

6
7A.2b

7

8

1

2

3

4

5

6
7A.3b

7
1

8
2

3

4

5

6
7A.4b

7
1

8
2

3

4

5

6
7A.5b

7
1

8
2

3

4

5

6

7

8

d. Waste Treatment Efficiency
[enter 2 character code]
7A.1d

7A.2d

7A.3d

7A.4d

7A.5d

If additional pages of Part II, Section 6.2/7A are attached, indicate the total number of pages in this box
and indicate the Part II, Section 6.2/7 page number in this box:
EPA Form 9350 -1 (Rev. 08/2006) - Previous editions are
obsolete.

(example: 1,2,3,etc.)
*For Dioxin or Dioxin-like compounds, report in grams/year
**Range Codes: A=1 - 10 pounds; B=11 - 499 pounds C= 500-999 pounds.

Form Approved OMB Number: 2070-0093
Approval Expires: 01/31/2008

(IMPORTANT: Type or print; read instructions before completing form)

Page 5 of 5

TRI Facility ID Number

FORM R
PART II. CHEMICAL-SPECIFIC INFORMATION (CONTINUED)

Toxic Chemical, Category or Generic Name

SECTION 7B. ON-SITE ENERGY RECOVERY PROCESSES
Check here if no on-site energy recovery is applied to any waste
stream containing the toxic chemical or chemical category.

Not Applicable (NA) -

Energy Recovery Methods [enter 3-character code(s)]

1

2

3

SECTION 7C. ON-SITE RECYCLING PROCESSES
Not Applicable (NA) -

Check here if no on-site recycling is applied to any waste
stream containing the toxic chemical or chemical category.

Recycling Methods [enter 3-character code(s)]

2

1

3

SECTION 8. SOURCE REDUCTION AND RECYLING ACTIVITIES
Column A
Prior Year
(pounds/year*)

Column B
Current Reporting Year
(pounds/year*)

Column C
Following Year
(pounds/year*)

Column D
Second Following Year
(pounds/year*)

8.1
8.1a
8.1b
8.1c

8.1d
8.2
8.3

Total on-site disposal to Class I
Underground InjectionWells, RCRA
Subtitle C landfills, and other landfills
Total other on-site disposal or other
releases
Total off-site disposal to Class I
Underground Injection Wells, RCRA
Subtitle C landfills, and other landfills
Total other off-site disposal or other
releases
Quantity used for energy recovery
onsite
Quantity used for energy recovery
offsite

8.4

Quantity recycled
onsite

8.5

Quantity recycled offsite

8.6

Quantity treated onsite

8.7

Quantity treated offsite

8.8

Quantity released to the environment as a result of remedial actions, catastrophic events,
or one-time events not associated with production processes (pounds/year)*

8.9

Production ratio or activity index

8.10

Did your facility engage in any source reduction activities for this chemical during the reporting
year? If not, enter “NA” in Section 8.10.1 and answer Section 8.11.
Source Reduction Activities
[enter code(s)]

Methods to Identify Activity (enter codes)

8.10.1

a.

b.

c.

8.10.2

a.

b.

c.

8.10.3

a.
a.

b.
b.

c.
c.

8.10.4
8.11

If you wish to submit additional optional information on source reduction, recycling, or pollution
control activities, check “Yes.”

EPA Form 9350 -1 (Rev. 08/2006) - Previous editions are obsolete.
report in grams/year

Yes
*For Dioxin or Dioxin-like compounds,